Intravascular Ultrasound versus Angiography for Lower Extremity Peripheral Artery Disease Endovascular...

We aimed to conduct a systematic review and study-level meta-analysis of randomized controlled trials and observational studies comparing intravascular ultrasound (IVUS) guidance with angiography guidance for peripheral artery disease (PAD) endovascular revascularization, as current evidence is lacking.

We searched Medline, Embase and CENTRAL from inception until November 22, 2025. Trials and observational studies were analyzed separately. We used random-effects as our primary analysis and assessed the certainty of evidence using GRADE. Key outcomes included restenosis, reintervention, major amputation, and mortality.

We included 2 randomized trials (n = 387), and 19 observational studies (n = 1,164,329). According to randomized data, IVUS-guidance likely reduces restenosis compared to angiography-guidance (RR 0.59, 95% CI 0.42 - 0.83; moderate certainty). However, IVUS may not reduce reintervention (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.44 - 1.08, low certainty), or mortality (RR 1.13, 95% 0.37 - 3.42, low certainty), while its effect on major amputation is very uncertain (RR 0.97, 95% 0.14 - 6.73, very low certainty). However, based on observational data, IVUS may reduce restenosis (RR 0.70, 95% CI 0.54 - 0.90, low certainty), reintervention (RR 0.66, 95% CI 0.48 -0.90, low certainty), major amputation (RR 0.83, 95% CI 0.72 - 0.96, low certainty), and mortality (RR 0.88, 95%CI 0.84, 0.93, low certainty).

IVUS guidance likely reduces restenosis based on limited randomized evidence. Observational studies suggest potential benefits across several outcomes, although the certainty of evidence is low. Larger randomized trials are required to clarify the potential benefits of IVUS guidance.